Is 1 milligram (mg) of morphine (opioid analgesic) administered intramuscularly (IM) an appropriate dose for pain management in a 6-year-old child weighing 70 pounds (approximately 31.8 kilograms)?

1 mg Morphine IM is Severely Underdosed and Should Not Be Used

This dose is approximately 10-fold lower than recommended and will not provide adequate pain relief for a 70-pound (31.8 kg) child. Additionally, the intramuscular route should be avoided when possible due to its painful nature and inability to allow dose titration. 1, 2

Correct Morphine Dosing for This Child

For severe pain requiring parenteral opioids, administer morphine 0.1 mg/kg IV/IM every 4-6 hours, which equals approximately 3.2 mg for this 31.8 kg child. 3 For moderate-to-severe pain in children aged 5-18 years, the recommended single IV dose is 200-300 mcg/kg (0.2-0.3 mg/kg), which would be 6.4-9.5 mg for this patient. 4

The 1 mg dose represents only 0.03 mg/kg—far below the therapeutic range of 0.05-0.1 mg/kg minimum recommended by the American Academy of Pediatrics. 3

Route Selection: Avoid IM When Possible

• The intramuscular route is explicitly discouraged because it causes pain at the injection site that persists for days, does not allow for medication titration, and provides no clinical advantage over other routes. 1, 2

• Intravenous administration is strongly preferred as it allows rapid pain relief, precise dose titration, and avoids additional procedural pain. 1, 3

• Alternative routes include intranasal or transmucosal fentanyl if IV access is unavailable, though intranasal may cause nasal mucosal burning. 1, 2

Pain Management Algorithm for This Patient

Step 1: Assess pain severity immediately upon presentation, as delays in pain treatment are common and harmful. 1

Step 2: For severe pain requiring opioids:

• Establish IV access if not already present 1
• Administer morphine 0.1-0.2 mg/kg IV (3.2-6.4 mg for this child) 3, 4
• Titrate with small additional doses every 15-20 minutes until pain is controlled 1

Step 3: Continuous monitoring is mandatory:

• Pulse oximetry and respiratory rate monitoring throughout treatment 4
• Have naloxone 0.1 mg/kg immediately available for reversal of respiratory depression 3, 4

Step 4: Consider adjunctive measures:

• Nonpharmacologic interventions including distraction techniques and family presence 2
• NSAIDs (ibuprofen 10 mg/kg every 6-8 hours) can be added for enhanced pain control if no contraindications exist 2, 4

Critical Pitfalls to Avoid

Never underdose opioids in children experiencing severe pain. Studies document that children, particularly children of color, systematically receive inadequate pain medication, and providers must work actively to ensure optimal pain management. 1

Never withhold pain medication while awaiting diagnosis. Multiple pediatric studies demonstrate that morphine does not mask symptoms or impair diagnostic accuracy—it actually facilitates examination by making children more comfortable and cooperative. 1, 2, 4

Never use scheduled around-the-clock opioid dosing without appropriate monitoring infrastructure. Patient-controlled analgesia or scheduled dosing requires continuous cardiorespiratory monitoring and oxygen saturation assessment. 1, 4

Specific Dosing Recommendations

For this 31.8 kg child with severe pain:

• Initial IV dose: 3.2-6.4 mg morphine (0.1-0.2 mg/kg) 3, 4
• Repeat dosing: Every 4-6 hours as needed 3
• Maximum consideration: Up to 0.3 mg/kg (9.5 mg) for severe pain 4

If IM route is absolutely unavoidable due to lack of IV access and unavailability of intranasal alternatives, the minimum effective dose would still be 3.2 mg (0.1 mg/kg), not 1 mg. 3